Journal of Athletic Training 2015;50(9):986–1000

doi: 10.4085/1062-6050-50.9.07
Ó by the National Athletic Trainers’ Association, Inc position statement
www.natajournals.org

National Athletic Trainers’

Association Position Statement:
Exertional Heat Illnesses
Douglas J. Casa, PhD, ATC, FNATA, FACSM*;
Julie K. DeMartini, PhD, ATC†; Michael F.
Bergeron, PhD, FACSM‡; Dave Csillan, MS,
ATC, LAT§; E. Randy Eichner, MD, FACSMjj;
Rebecca M. Lopez, PhD, ATC, CSCS¶; Michael
S. Ferrara, PhD, ATC, FNATA#; Kevin C.
Miller, PhD, ATC**; Francis O’Connor, MD,
MPH, FACSM††; Michael N. Sawka, PhD,
FACSM‡‡; Susan W. Yeargin, PhD, ATC§§
*University of Connecticut, Storrs; †Sacred Heart University,
Fairfield, CT; ‡Youth Sports of the Americas, Birmingham, AL;
§Ewing High School, NJ; jjUniversity of Oklahoma Health Sciences
Center, Oklahoma City; ¶University of South Florida, Tampa;
#University of New Hampshire, Durham; **Central Michigan
University, Mount Pleasant; ††Uniformed Services University,
Bethesda, MD; ‡‡Georgia Institute of Technology, Atlanta;
§§University of South Carolina, Columbia

Objective: To present best-practice recommendations for
the prevention, recognition, and treatment of exertional heat
illnesses (EHIs) and to describe the relevant physiology of
thermoregulation.
Background: Certified athletic trainers recognize and treat
athletes with EHIs, often in high-risk environments. Although the
proper recognition and successful treatment strategies are well
documented, EHIs continue to plague athletes, and exertional
heat stroke remains one of the leading causes of sudden death
during sport. The recommendations presented in this document
provide athletic trainers and allied health providers with an
integrated scientific and clinically applicable approach to the
prevention, recognition, treatment of, and return-to-activity
guidelines for EHIs. These recommendations are given so that
proper recognition and treatment can be accomplished in order
to maximize the safety and performance of athletes.
Recommendations: Athletic trainers and other allied health
care professionals should use these recommendations to
establish onsite emergency action plans for their venues and
athletes. The primary goal of athlete safety is addressed through
the appropriate prevention strategies, proper recognition tactics,
and effective treatment plans for EHIs. Athletic trainers and
other allied health care professionals must be properly educated
and prepared to respond in an expedient manner to alleviate
symptoms and minimize the morbidity and mortality associated
with these illnesses.
Key Words: heat cramps, heat syncope, heat exhaustion,
heat injury, heat stroke, dehydration

T
he prevention, recognition, and treatment of exer-
tional heat illnesses (EHIs) are core components of
sports medicine services at all levels of sport. The
risk of EHI is ever present during exercise in the heat but
can also occur in ‘‘normal’’ environmental conditions. Our
current knowledge base has allowed us to greatly enhance
the level of care that can be provided for athletes with these
medical conditions. This document serves as the current
position statement for the National Athletic Trainers’
Association (NATA) and replaces the document that was
published in 2002.1
The care of exertional heat-stroke (EHS) patients has
come a long way in the past millennia. We now possess the
knowledge to nearly assure survival from this potentially
fatal injury if EHS is quickly and appropriately recognized
and treated at the time of collapse.2,3 Additionally, our
knowledge base and proven management protocols allow
us to establish effective prevention and management
strategies to minimize the risk of and improve the outcome

986 Volume 50  Number 9  September 2015

from EHS, thereby affecting public health via policy
creation and modification.
DEFINITIONS OF EHIs
Exercise-Associated Muscle Cramps
Exercise-associated muscle cramps (EAMCs) are sudden
or sometimes progressively and noticeably evolving,
involuntary, painful contractions of skeletal muscle during
or after exercise.4,5 Heat cramps is a popular but technically
inappropriate term for a certain category of EAMCs
because they are not directly related to an elevated body
temperature,5,6 do not readily occur after passive heating at
rest, and can present during exercise in warm or even cool6–
8
and temperature-controlled conditions,9 although exten-
sive sweating is typical. The signs and symptoms of
incipient EAMCs can be described as tics, twinges,
stiffness, tremors, or contractures, but these terms refer to
conditions that are typically painless and do not demon-
strate muscle activity on electromyography, unlike full-
blown EAMCs.10 The cause of EAMCs is not fully
confirmed; proposed contributing factors and conditions
include dehydration,5 electrolyte imbalances,5,11 altered
neuromuscular control,4 fatigue, or any combination of
these factors.5–10
Heat Syncope
Heat syncope, or orthostatic dizziness, often occurs in
unfit or heat-unacclimatized persons who stand for a long
period of time in the heat or during sudden changes in
posture in the heat, especially when wearing a uniform or
insulated clothing that encourages and eventually leads to
maximal skin vasodilation. This condition is often attribut-
ed to dehydration, venous pooling of blood, reduced cardiac
filling, or low blood pressure with resultant cerebral
ischemia.12 Heat syncope usually occurs during the first 5
days of unaccustomed heat exposure (eg, during the
preseason), before the blood volume expands and cardio-
vascular adaptations are complete, and in those with heart
disease or taking diuretics.13
Heat Exhaustion
Heat exhaustion is the inability to effectively exercise in
the heat, secondary to a combination of factors, including
cardiovascular insufficiency, hypotension, energy deple-
tion, and central fatigue.14 This condition is manifested by
an elevated core body temperature (usually ,40.58C) and
is often associated with a high rate or volume of skin
blood flow, heavy sweating, and dehydration.15 It occurs
most frequently in hot or humid (or both) conditions, but it
can also occur in normal environmental conditions with
intense physical activity. Heat exhaustion most often
affects heat-unacclimatized or dehydrated individuals with
a body mass index .27 kg/m.16 By definition, absent from
heat exhaustion are end-organ damage, which would
indicate heat injury (eg, renal insufficiency, rhabdomyol-
ysis, or liver injury), and significant central nervous
system (CNS) dysfunction with marked temperature
elevation (.40.58C [1058F]), which would indicate the
possibility of EHS.
Exertional Heat Injury
Heat injury is a moderate to severe heat illness
characterized by organ (eg, liver, renal) and tissue (eg,
gut, muscle) injury associated with sustained high body
temperature resulting from strenuous exercise and environ-
mental heat exposure. Body temperature is usually but not
always greater than 40.58C (1058F).17,18
Exertional Heat Stroke
Exertional heat stroke is the most severe heat illness. It is
characterized by neuropsychiatric impairment and a high
core body temperature, typically .40.58C (1058F).16,19 This
condition is a product of both metabolic heat production
and environmental heat load and occurs when the
thermoregulatory system becomes overwhelmed due to
excessive heat production (ie, metabolic heat production
from the working muscles) or inhibited heat loss (ie,
decreased sweating response, decreased ability to evaporate
sweat) or both. Although this illness is most likely to occur
in hot and humid weather, it can manifest with intense
physical activity in the absence of extreme environmental
conditions. The first sign of EHS is often CNS dysfunction
(eg, collapse, aggressiveness, irritability, confusion, sei-
zures, altered consciousness).19 A medical emergency, EHS
can progress to a systemic inflammatory response and
multi-organ system failure unless promptly and correctly
recognized and treated. The risks of morbidity and
mortality increase the longer an individual’s body temper-
ature remains elevated above the critical threshold
(.40.58C [1058F]) and are significantly reduced if body
temperature is lowered promptly.20
RECOMMENDATIONS
The NATA advocates the following prevention, recogni-
tion, and treatment strategies for EHIs. These recommen-
dations are presented to help certified athletic trainers and
other health care providers maximize health, safety, and
sport performance. However, individual responses to
physiologic stimuli and environmental conditions vary
widely. Therefore, these recommendations do not guarantee
full protection from exertional heat-related illnesses but
could mitigate the risks associated with athletic participa-
tion and physical activity. These recommendations and
prevention strategies should be carefully considered and
implemented by certified athletic trainers and the health
care team as part of an overall strategy for the prevention
and treatment of EHIs. The strength of each recommenda-
tion follows the Strength of Recommendation taxonomy
(SORT; Table 1).21
Prevention
1. Conduct a thorough, physician-supervised preparticipa-
tion medical screening before the start of the season to
identify athletes with risk factors for heat illness or a
history of heat illness (Table 2).22,23 Strength of
recommendation: C
2. Individuals should be acclimatized to the heat gradually
over 7 to 14 days.22–26 Heat acclimatization involves
progressively increasing the intensity and duration of
physical activity and phasing in protective equipment (if
Journal of Athletic Training 987
Table 1. Strength of Recommendation Taxonomy (SORT)a
Strength of Recommendation Definition
A Recommendation based on consistent and good quality experimental evidence (morbidity, mortality,
exercise and cognitive performance, physiologic responses).
B Recommendation based on inconsistent or limited quality experimental evidence.
C Recommendation based on consensus; usual practice; opinion; disease-oriented evidenceb; case series or
studies of diagnosis, treatment, prevention, or screening; or extrapolations from quasi-experimental
research.
a
Reprinted with permission from Ebell MH, Siwek J, Weiss BD, et al, Strength of recommendation taxonomy (SORT): a patient-centered
approach to grading evidence in the medical literature, 2004;69(3):548–556, Am Fam Physician. Copyright 2004 American Academy of
Family Physicians. All Rights Reserved.14
b
Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptoms improvement, cost reduction, and
quality of life. Disease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect
improvements in patient outcomes (eg, blood pressure, blood chemistry, physiologic function, pathologic finding).

applicable). If heat acclimatization is not maintained, the
physiologic benefits provided by this process will decay
within 3 weeks.24–26 The first 2–3 weeks of preseason
practice typically present the greatest risk of EHI,
particularly in equipment-intensive sports.26,27–29 All
possible preventive measures should be used during this
time to address this high-risk period (Figure 1). Strength
of recommendation: B
3. Athletes who are currently sick with a viral infection (eg,
upper respiratory tract infection or gastroenteritis) or
other illness or have a fever or serious skin rash should
not participate until the condition is resolved.16,27,30 Even
after symptoms resolve, the athlete may still be
susceptible to heat illness and should be observed
carefully upon return to exercising in the heat. Strength
of recommendation: B
4. Individuals should maintain euhydration and appropriate-
ly replace fluids lost through sweat during and after
games and practices (see the NATA position statement on
fluid replacement in athletes31). Players should have free
access to readily available fluids at all times, not just
during designated breaks. Instruct them to eat or drink
Table 2. Sample Preparticipation Physical Examination Questions
Related to Exertional Heat Stroke69
1. Have you ever previously been diagnosed with exertional heat
stroke? If yes
a. How long ago?
b. Have you had any complications since then?
c. How long did it take you to return to full participation?
d. Did you have any complications upon your return to play?
e. Was an exercise heat tolerance test conducted to assess your
thermoregulatory capacity?
2. Have you ever been diagnosed with heat exhaustion? If yes
a. When?
b. How many times?
3. Have you ever had trouble or complications from exercising in the
heat (eg, feeling sick, throwing up, dizzy, lack of energy, decreased
performance, muscle cramps)?
4. How much training have you been doing recently (in the past 2
weeks)? Has this been performed in warm or humid weather?
5. Have you been training during the last 2 months? Would you say
you are in poor, good, or excellent condition?
6. Describe your drinking habits. (Are you conscious of how much you
consume? Is your urine consistently dark?)
7. Would you consider yourself a heavy or a salty sweater?
8. How many hours of sleep do you get per night? Do you sleep in an
air-conditioned room?
9. Do you take any supplements or ergogenic aids?
appropriate sodium-containing fluids and foods to help
replace sodium losses in sweat and urine and to enhance
hydration (ie, water retention and distribution). The aims
of fluid consumption or replacement are to prevent a body
mass loss of more than 2% (as measured before and after
the practice or game) and to keep morning urine light in
color.31,32 These strategies may reduce the risk of acute
and chronic significant dehydration and decrease the risk
of EHI.27,31–34 Strength of recommendation: B
5. The sports medicine staff must educate relevant personnel
(ie, coaches, administrators, security guards, emergency
medical services [EMS] staff, athletes) on preventing and
recognizing EHI and, in particular, EHS.35,36 Signs and
symptoms of a medical emergency should be reviewed,
and every institution should have and personnel should
practice an emergency action plan specific to each
practice and game site. Review and rehearsal of the
emergency action plan should include all relevant
members of the sports medicine team (ie, coaches,
athletic trainers, EMS). Strength of recommendation: C
6. Appropriate medical care must be available, and all
personnel must be familiar with EHI prevention,
recognition, and treatment.35–37 Certified athletic trainers
and other health care providers covering practices or
events are the primary providers of medical care for
athletes who display signs or symptoms of EHI and have
the authority to restrict an athlete from participating if
EHI is suspected or to refer the athlete for a significant
EHI condition. Strength of recommendation: C
7. When environmental conditions warrant, a cold-water or
ice tub and ice towels should be available to immerse or
soak a patient with a suspected heat illness. 33,37
Immediate whole-body cooling is essential for treating
EHI and EHS in particular. Onsite facilities are needed
for immediate treatment. Strength of recommendation: B
8. The assessment of rectal temperature is the clinical gold
standard for obtaining core body temperature of patients
with EHS38 and the medical standard of practice and
accepted protocol. No other field-expedient methods of
obtaining core body temperature (eg, oral, axillary,
tympanic, forehead sticker, temporal) are valid or reliable
after intense exercise in the heat, and they may lead to
inadequate or inappropriate treatment, thereby endanger-
ing a patient’s health.38–41 Parents, administrators,
coaches, and student-athletes should be educated ahead
of time that this procedure will be used for heat-illness
emergencies, especially in patients suspected of having
heat exhaustion or EHS. Esophageal and gastrointestinal

988 Volume 50  Number 9  September 2015

Figure 1. National Collegiate Athletic Association heat-acclimatization guidelines.
(via ingestible thermistor) measurements may be appro-
priate alternatives for temperature assessment but require
advanced training for the former and careful planning for
the latter. Under all circumstances in which EHS is
possible, a rectal temperature assessment should be able
to be obtained. Strength of recommendation: A
9. Because the effects of heat are cumulative, athletes
should be encouraged to sleep at least 7 hours per night in
a cool environment; eat a balanced diet; and properly
hydrate before, during, and after exercise.16 Individuals
should also be advised to rest in a cool environment
during periods of inactivity (eg, off days, between
sessions on double-practice days) to maximize recovery.
Rest periods should incorporate meal times and allow 2 to
3 hours for food, fluids, electrolytes (primarily sodium
and chloride), and other nutrients to be digested and
absorbed before the next practice or competition. Strength
of recommendation: C
10. To anticipate potential problems, a preseason heat-
acclimatization policy should be developed for organized
sports and event guidelines formulated for hot, humid
weather conditions based on the type of activity and wet-
bulb globe temperature (WBGT).23,26 In stressful envi-
ronmental conditions, particularly during the first 2–3
weeks of preseason practice, activity should be delayed or
rescheduled or the practice session shortened to reduce
the risk to participants. Special attention should be given
to practice drills that involve high-intensity activity and
full protective equipment worn by players, as these
factors may exacerbate the amount of heat stress on the
body. Strength of recommendation: B
11. Individuals who may be particularly susceptible to EHI
must be identified.42–45 They should be closely monitored
during stressful environmental conditions, and preventive
steps should be taken.45,46 In addition, emergency
supplies and equipment (eg, tubs for cold-water immer-
sion [CWI], rectal thermometer) should be onsite, easily
accessible, and in good working order to allow for
immediate intervention and treatment if needed. Strength
of recommendation: B
12. Rest breaks should be planned and the work-to-rest ratio
modified to match the environmental conditions and the
intensity of the activity.45–47 Breaks should be in the
shade or in a predetermined cooling zone and should
allow enough time for all athletes to consume fluids.
Additionally, players should be permitted to remove
equipment (eg, helmets) during rest periods. Strength of
recommendation: B
13. The use of dietary supplements and other substances that
have a dehydrating effect, increase metabolism, or affect
body temperature and thermoregulation is discouraged.48
Because supplements may increase the risk of EHI, their
use should be carefully monitored. Strength of recom-
mendation: C
14. Minimal experimental evidence exists regarding the most
effective method of preventing EAMCs due to the variety
of causes. Supplemental sodium ingestion and fluid
monitoring9 or neuromuscular reeducation49 may help to
prevent EAMC recurrences. Clinicians should identify the
patient’s unique intrinsic (eg, hydration, acclimatization,
biomechanics, training status) and extrinsic (eg, climate
conditions, exercise intensity) risk factors that preceded
EAMCs before implementing a prevention strategy.
Strength of recommendation: C
Recognition
Exercise-Associated Muscle Cramps.
15. A patient experiencing EAMCs will likely show 1 or
more of the following signs and symptoms: visible
cramping in part or all of the muscle or muscle groups,
localized pain, dehydration, thirst, sweating, or fa-
tigue.4,5,50 Strength of recommendation: C
16. A thorough medical history should be obtained to
distinguish muscle cramping as a result of an underlying
clinical condition (eg, sickle cell trait) from EAMCs.50
The latter is often preceded by subtle muscle twitching,4
whereas the former is not. Strength of recommendation: C
17. Most EAMCs related to overload or fatigue tend to be
short in duration (less than 5 minutes) and mild in
Journal of Athletic Training 989
 severity.7,51 However, some EAMCs severely affect
athletic performance and as a result, prohibit further
exercise; require further medical attention to resolve; or
elicit soreness for several days.7,49–51 Strength of recom-
mendation: B
Heat Syncope.
18. A patient who experiences a brief episode of fainting
associated with dizziness, tunnel vision, pale or sweaty
skin, and a decreased pulse rate while standing in the heat
or after vigorous exercise (with a relatively low rectal
temperature [,398C]) is likely experiencing heat synco-
pe.12 However, responsiveness, breathing, and pulse must
be assessed to rule out a cardiac event, which can present
with similar signs and symptoms but is a more serious
condition. Strength of recommendation: B
19. A thorough medical history and physical examination
should be performed to eliminate any other medical
conditions that could cause syncope. Strength of recom-
mendation: C
Exertional Heat Exhaustion.
20. Heat exhaustion may be present if the patient demon-
strates excessive fatigue, faints, or collapses with minor
cognitive changes (eg, headache, dizziness, confusion)
while performing physical activity,15 yet the athletic
trainer should assess the patient’s CNS function by noting
any bizarre behavior, hallucinations, altered mental
status, confusion, disorientation, or coma that may
indicate a more serious condition such as EHS. Other
signs and symptoms of exertional heat exhaustion may
include fatigue, weakness, dizziness, headache, vomiting,
nausea, lightheadedness, low blood pressure, and im-
paired muscle coordination. Strength of recommendation:
B Exercise-Associated Muscle Cramps.
21. It is strongly recommended that a rectal temperature be
obtained to differentiate exertional heat exhaustion from
the more serious EHS. With heat exhaustion, core body
temperature (measured rectally) is usually less than
40.58C (1058F), a key characteristic that differentiates it
from EHS. Strength of recommendation: A
Exertional Heat Stroke.
22. The 2 main diagnostic criteria for EHS are CNS
dysfunction and a core body temperature greater than
40.58C (1058F).16,19,52 However, if a suspected EHS
victim exhibits CNS dysfunction even though the rectal
temperature is slightly lower (ie, 408C [1048F]), it is
prudent to assume the patient is suffering from EHS and
begin the appropriate treatment. After initial collapse,
recognition is often delayed, and the patient may begin to
cool passively, dropping below the 40.58C (1058F)
threshold. Rectal temperature thermometry is the only
method of obtaining an immediate and accurate mea-
surement of core body temperature. Other devices, such
as oral, axillary, aural canal, tympanic, forehead sticker,
and temporal artery thermometers, inaccurately assess the
body temperature of an exercising person.38–41 A delay in
accurately assessing temperature during diagnosis may
also explain a body temperature that is lower than
expected. Strength of recommendation: A
23. Because immediate treatment is vital in EHS, it is
important to not waste time by substituting an invalid
method of temperature assessment if rectal thermometry
990 Volume 50  Number 9  September 2015
is not available. Instead, the practitioner should rely on
other key diagnostic indicators (ie, CNS dysfunction,
circumstances of the collapse). If EHS is suspected, CWI
(or another rapid cooling mechanism if CWI is not
available) should be initiated immediately. Strength of
recommendation: C
24. In a patient suspected of having EHS, CNS function
should be assessed. Signs and symptoms can include
disorientation, confusion, dizziness, loss of balance,
staggering, irritability, irrational or unusual behavior,
apathy, aggressiveness, hysteria, delirium, collapse, loss
of consciousness, and coma. In some cases, a lucid
interval may be present; however, if EHS is present, the
patient will likely deteriorate quickly. Strength of
recommendation: B
25. Other signs and symptoms of EHS that may be present
include dehydration, hot and wet skin, hypotension, and
hyperventilation. Most patients with EHS have hot,
sweaty skin as opposed to those with the classical type
of heat stroke (the passive condition that typically affects
children and the elderly), who present with dry skin.
(Table 3). Strength of recommendation: B
Heat Injury.
26. Heat injury is a moderate to severe heat illness
characterized by end-organ damage but the absence of
the profound CNS dysfunction often found with EHS.17,18
Evaluation usually reveals very dark (cola-colored) urine,
severe muscle pain, and abnormal blood chemistry levels.
Strength of recommendation: B
Treatment
27. The immediate treatment for acute EAMCs related to
muscle overload or fatigue is rest and passive static
stretching of the affected muscle until cramps abate.7,51,53
Icing, massage, or both may also help relieve some of the
discomfort after EAMCs.5 For EAMCs related to
excessive sweating and a suspected whole-body sodium
deficit, the patient must ingest sodium-containing fluids
(preferably) or foods (or both) to help return the body to
normal fluid, electrolyte, and energy distribution. Strength
of recommendation: B
28. Fluid absorption, retention, and distribution are enhanced
by beverages that contain sodium and carbohydrates. A
high-sodium product (eg, salt packet) may be added to a
beverage to help offset sodium lost via exercise-induced
sweating. Similarly, small volumes (eg, 1 mL per 1 kg
body weight) of a salty solution such as pickle juice may
be consumed, if tolerated, without negatively affecting ad
libitum water ingestion,54 plasma electrolyte concentra-
tions,55 or thirst or causing nausea or stomach fullness.54
Strength of recommendation: B
29. Patients with EAMCs are normally conscious and
responsive and have normal vital signs.50 Thus, clinicians
can provide fluids orally to a patient suffering from
EAMCs who is compliant and tolerating fluid intake. The
use of intravenous fluids should be considered if the
patient is noncompliant or unable to tolerate fluids.5
Strength of recommendation: A
30. Patients with recurring EAMCs should undergo a
thorough medical screening to rule out more serious
Table 3. Clinical Distinctions of Exertional Heat Illnesses
Exercise-Associated
Characteristic Muscle (Heat) Cramps
Description Acute, painful, involuntary
muscle contractions
presenting during or after
exercise
Physiologic cause Dehydration, electrolyte
imbalances, and/or
neuromuscular fatigue
Primary treatment Stop exercising, provide
factors sodium-containing
beverages
Recovery Often occurs within minutes
to hours
Heat Illness
Heat Syncope
Collapsing in the heat,
resulting in loss of
consciousness
Standing erect in a hot
environment, causing
postural pooling of
blood in the legs
Lay patient supine and
elevate legs to restore
central blood volume
Often occurs within
hours
Exertional Heat
Heat Exhaustion Stroke
Inability to continue Severe hyperthermia
exercise due to leading to overwhelming
cardiovascular of the thermoregulatory
insufficiency system
High skin blood flow, High metabolic heat
heavy sweating, and/or production and/or
dehydration, causing reduced heat dissipation
reduced venous return
Cease exercise, remove Immediate whole-body
from hot environment, cold-water immersion to
elevate legs, provide quickly reduce core body
fluids temperature
Often occurs within 24 h; Highly dependent on initial
same-day return to play care and treatment; further
not advised medical testing and physician
clearance required before
return to activity

neuromuscular conditions (eg, fatigue, hydration level,
improper nutrition).50 Strength of recommendation: C
Heat Syncope.
31. The clinician should move the patient to a shaded area,
monitor vital signs, elevate the legs above the level of the
heart, cool the skin, and rehydrate.12 Strength of
recommendation: C
Exertional Heat Exhaustion.
32. Removing any excess clothing and equipment increases
the evaporative surface of the skin and facilitates cooling.
Strength of recommendation: C
33. The patient should be moved to a cool or shaded area.
Further body cooling should be accomplished via fans or
ice towels if necessary. Strength of recommendation: C
34. While monitoring vital signs, the clinician should place
the patient in the supine position with legs elevated above
the level of the heart to promote venous return.15,16,56
Strength of recommendation: C
35. If intravenous fluids are needed or if recovery is not rapid
(within 30 minutes of initiation of treatment) and
uneventful, fluid replacement should begin and the
patient’s care transferred to a physician. If the condition
worsens during or after treatment, EMS should be
activated.15,16 Additionally, rectal temperature should be
obtained; if .40.58C (1058F), the patient should be
treated for EHS. Strength of recommendation: C
Exertional Heat Stroke.
36. For any EHS patient, the goal is to lower core body
temperature to less than 38.98C (1028F) within 30 minutes
of collapse.20 Body cooling serves 2 purposes: returning
blood flow from the skin to the heart and lowering core
body temperature by reducing the hypermetabolic state of
the organs. The length of time the core body (and
particularly the brain) is above the critical temperature
threshold (40.58C [1058F]) dictates morbidity and the risk
of death from EHS (Figure 2).57,58 Strength of recom-
mendation: B
37. When EHS is suspected, the patient’s body (trunk and
extremities) should be quickly immersed in a pool or tub
of cold water. Removing excess clothing and equipment
will enhance cooling by maximizing the surface area of
the skin. However, because removing excess clothing and
equipment can be time consuming, CWI should begin
immediately and equipment should be removed while the
patient is in the tub (or while temperature is being
assessed or the tub is being prepared).59 Rectal temper-
ature and other vital signs should be monitored during
cooling every 5 to 10 minutes if a continuous monitoring
device is not available.20,60 Strength of recommendation:
B
38. Cold-water immersion up to the neck is the most effective
cooling modality for patients with EHS.57 The water
should be approximately 1.78C (358F) to 158C (598F) and
stirred continuously to maximize cooling. The patient
should be removed when core body temperature reaches
38.98C (1028F) to prevent overcooling (Table 4).60
Strength of recommendation: A
39. Although cooling rates may vary, the cooling rate for CWI
will be approximately 0.28C/min (0.378F/min) or about 18C
every 5 minutes (or 18F every 3 minutes) when considering
the entire immersion period from postcollapse to 38.98C
(1028F).20,57,58 Strength of recommendation: B
40. If full-body CWI is not available, partial-body immersion
(ie, torso) with a small pool or tub and other modalities,
such as wet ice towels rotated and placed over the entire
body or cold-water dousing with or without fanning, may
be used but are not as effective as CWI.61,62 Strength of
recommendation: B
41. If a physician is onsite (as in a mass medical tent
situation) and can manage the EHS, then transportation to
a medical facility may not be necessary if cooling
occurred immediately (ie, if the duration above 408C
[1048F] was less than 30 minutes) and the patient is
asymptomatic 1 hour postcooling. If a physician is not
present but other medical staff (eg, AT, EMS, nurse) are
onsite, aggressive cooling should continue until the
patient’s temperature is 398C (102.88F). When medical
staff is onsite, all patients with EHS should be cooled first
and transported second. However, when medical staff is
not present and EHS is suspected, then the coaching

Journal of Athletic Training 991


Figure 2. Relationship between severity of hyperthermia and rat
survivability. Reprinted with permission. Casa DJ, Kenny JP,
Taylor NAS. Immersion treatment for exertional hyperthermia:
cold or temperate water? Med Sci Sports Exerc. 2010;42(7):1246–
1252. Promotional and commercial use of the material in print,
digital, or mobile-device format is prohibited without the permis-
sion from publisher Wolters Kluwer Health. Please contact
lwwjournalpermissions@wolterskluwer.com for further informa-
tion.
staff/supervisors should implement cooling until medical
assistance arrives. Strength of recommendation: B
42. Policies and procedures for cooling patients before
transport to the hospital must be explicitly stated in an
emergency action plan and shared with potential EMS
responders so that treatment of EHS by all medical
professionals is coordinated (Figure 3). Strength of
recommendation: B
Return to Activity
43. In cases of EAMCs or heat syncope, the athletic trainer
should monitor the patient’s condition until signs and
symptoms are no longer present. Strength of recommen-
dation: C
44. In patients with heat exhaustion, same-day return to
activity is not recommended and should be avoided.15,56
Strength of recommendation: C
45. Many patients with EHS are cooled effectively and sent
home the same day63; they may be able to resume
modified activity within 1 month with a physician’s
clearance. However, when treatment is delayed (ie, not
provided within 30 minutes), patients may experience
residual complications for months or years after the event.
Strength of recommendation: C
46. Most guidelines suggest that a patient recovering from
EHS be asymptomatic with normal blood-work results
(renal and hepatic panels, electrolytes, and muscle
enzyme levels) before a gradual return to activity is
initiated.64 Unfortunately, few evidence-based strategies
have been developed to determine recovery of the
992 Volume 50  Number 9  September 2015
Table 4. Guidelines for Implementing Cold-Water Immersion for a
Patient With Exertional Heat Stroke
1. Initial response. Once exertional heat stroke is suspected, prepare
to cool the patient and contact emergency medical services.
2. Prepare for ice-water immersion. On the playing field or in close
proximity, half-fill a stock tank or wading pool with water and ice
(make sure there is a sufficient water source).
a. The tub can be filled with ice and water before the event begins
(or have the tub half-filled with water and keep 3 to 4 coolers of
ice next to the tub; this prevents having to keep the tub cold
throughout the day.
b. Ice should cover the surface of the water at all times.
c. If the athlete collapses near the athletic training room, a whirlpool
tub or cold shower may be used.
3. Determine vital signs. Immediately before immersing the patient,
obtain vital signs.
a. Assess core body temperature with a rectal thermistor.
b. Check airway, breathing, pulse, and blood pressure.
c. Assess the level of central nervous system dysfunction.
4. Begin ice-water immersion. Place the patient in the ice-water–
immersion tub. Medical staff, teammates/coaches, and volunteers
may be needed to assist with entry to and exit from the tub.
5. Total-body coverage. Cover as much of the body as possible with
ice water while cooling.
a. If full-body coverage is not possible due to the tub size, cover
the torso as much as possible.
b. To keep the patient’s head and neck from going under water, an
assistant may hold him or her under the axillae with a towel or
sheet wrapped across the chest and under the arms.
c. Place an ice/wet towel over the head and neck while body is
being cooled in the tub.
d. Use a water temperature under 158C (608F).
6. Vigorously circulate the water. During cooling, water should be
continuously circulated or stirred to enhance the water-to-skin
temperature gradient, which optimizes cooling. Have an assistant
stir the water during cooling.
7. Continue medical assessment. Vital signs should be monitored at
regular intervals.
8. Fluid administration. If a qualified medical professional is available,
an intravenous fluid line can be placed for hydration and support of
cardiovascular function.
9. Cooling duration. Continue cooling until the patient’s rectal
temperature lowers to 38.98C (1028F).
a. If rectal temperature cannot be measured and cold-water
immersion is indicated, cool for 10–15 min and then transport to
a medical facility.
b. An approximate estimate of cooling via cold-water immersion is
18C for every 5 min and 18C for every 3 min (if the water is
aggressively stirred). For example, someone in the tub for 15 min
would cool approximately 38C or 58C during that time.
10. Patient transfer. Remove the patient from the immersion tub only
after rectal temperature reaches 38.98C (1028F) and then transfer
to the nearest medical facility via emergency medical services as
quickly as possible.
thermoregulatory system,65 so the medical professional
must use clinical cues such as ongoing signs and
symptoms, responses to a standard exercise heat-tolerance
test, responses to gradually increasing exercise demands,
and ability to acclimatize to the heat to make return-to-
play decisions. Strength of recommendation: C
47. In all cases of EHS, after the patient has completed a 7- to
21-day rest period, demonstrated normal blood-work
results, and obtained physician clearance, he or she may
begin a progression of physical activity, supervised by the
athletic trainer or other medical professional with
knowledge of EHS treatment and care, from low intensity
Figure 3. Algorithm for treatment of exertional heat stroke.
to high intensity and increasing duration in a temperate
environment, with equipment added gradually where
indicated. Also, a graded progression of heat acclimati-
zation, while monitoring for signs and symptoms of EHI,
should be completed. The ability to progress depends
largely on the treatment provided, and in some rare cases,
full recovery may not be possible. Rectal temperature and
heart rate should be monitored during these activities, and
if the patient experiences any side effects or negative
symptoms with training, the progression should be
slowed, delayed, or stopped.65,66 Strength of recommen-
dation: C
48. Although structured guidelines for return to play after
EHS in athletics are lacking, the US military has adopted
effective recommendations for the proper progression of
return to duty after an episode of EHS. The main
considerations are treating any associated sequelae and, if
possible, identifying the cause of EHS, so that future
episodes can be prevented.65–67 As evidence-based
medicine research has advanced, the role of exercise
heat-tolerance testing has gained favor as a common-
sense approach: a patient who has a poor test result should
not increase activity at that point. However, the
significance of a normal test result and its relationship
with clearance to return to play still need to be refined and
evaluated. In either circumstance, monitoring the physi-
ologic response to series of challenging exercise heat
exposures is a large step forward in our delivery of health
care to the EHS patient who is recovering and working
toward a return to physical activity as a laborer, soldier, or
athlete. This method has proved effective within the
Israeli military68 and the US military and at the Korey
Stringer Institute, and it supports many of the consider-
ations put forth by the American College of Sports
Medicine and US military.65,67,69 Strength of recommen-
dation: C
BACKGROUND AND REVIEW OF THE LITERATURE
Thermoregulation
Thermoregulation is a complex interaction of the CNS,
the cardiovascular system, and the skin to maintain a core
body temperature of approximately 378C (98.68F).17,34,70,71
The CNS temperature-regulation center, located in the
Journal of Athletic Training 993
hypothalamus, is where the core temperature setpoint is
determined. The hypothalamus receives information re-
garding core body temperature and skin temperature from
peripheral skin receptors and the circulating blood. This
interaction regulates core body temperature via an open-
ended feedback loop similar to a home thermostat system.
Based on the peripheral feedback sent to the hypothalamus,
the body adjusts accordingly to initiate the appropriate
heat-transfer responses. If core temperature falls below the
normal setpoint, peripheral vasoconstriction and shivering
responses increase core body temperature, whereas if core
temperature rises above the normal setpoint, cutaneous
vasodilation and increased sweating occur to dissipate
heat.70,71
Core body temperature is determined by metabolic heat
production and the transfer of body heat to and from the
surrounding environment by the following heat-balance
equation71:
S ¼ Mð6 workÞ  E6R6C6K; ð1Þ
where S is the amount of stored heat, M is the metabolic
heat production, E is the evaporative heat loss, R is the heat
gained or lost by radiation, C is the heat lost or gained by
convection, and K is the heat lost or gained by conduction.
Basal metabolic heat production while fasting and at
absolute rest is approximately 60 to 70 kcal/h for an
average adult, with 50% of the heat being produced by
internal organs.72 Metabolic heat produced by intense
exercise may approach 1000 kcal/h, with more than 90% of
the heat resulting from metabolism in muscles.72 Heat is
further gained or lost by 1 or more of the following
mechanisms.72
Radiation: Heat is transferred to or from an object or
body via electromagnetic radiation (ie, sunlight) from
higher to lower energy surfaces.
Conduction: Heat is transferred from warmer to cooler
objects through direct physical contact (eg, ice packs).
Convection: Heat is transferred to or from the body to
surrounding fluid or air (eg, moving air from a fan or
immersion in water).
Evaporation: Heat is transferred via the vaporization of
sweat. This is the most efficient means of heat transfer. The
evaporation of sweat from the skin depends on the water
saturation of the air (ie, humidity level) and the velocity of
the moving air (ie, wind speed).17,30,70–73 The effectiveness
of evaporation for heat loss from the body diminishes
rapidly when the humidity level is high.
Exercise-Associated Muscle Cramps
The most common EHI experienced by athletes is
EAMCs.74 They afflict adolescents,9 adult athletes,7,51,74,75
soldiers, and industrial workers. They are seemingly
unpredictable, though affected athletes often report muscle
twinges before they experience full-blown, debilitating
muscle cramping. Probably because spinal inhibition is
weakest when a muscle contracts forcefully while short-
ened, EAMCs usually occur when muscles are in this
position.76 Although they may occur in any muscle,
EAMCs related to muscle overload or fatigue tend to
affect exercising (or constantly loaded) muscles, especially
those that cross 2 joints in the lower extremities (eg,
gastrocnemius, hamstrings).7 Patients experiencing EAMCs
994 Volume 50  Number 9  September 2015
typically display a transient inability to continue normal
activity and may have muscle soreness for days postcramp-
ing.50
Their cause is controversial,4,10 but a growing body of
experimental,76–79 quasiexperimental,6–8,51,75 and case49
studies suggest that EAMCs are not the result of
dehydration or electrolyte losses. Although athletes prone
to EAMCs may have substantial fluid (2 to 3.4 L/h) and
sodium (up to 5 g or far more in a single session) losses,9,11
the volume of fluid ingested, 11 postexercise body
weights,7,8,11 and gross sweat losses11 are often comparable
with those of noncramping athletes. These findings
underscore that such measures (or blood sodium concen-
tration) do not necessarily indicate a whole-body sodium
deficit. Potential risk factors for EAMCs consistent across
several prospective cohort studies7,51,75,80 include a history
of EAMCs; faster competition performance times; and prior
muscle, tendon, or ligament injury. In contrast, stretching
history, muscle flexibility, training frequency or volume,
height, age, body mass index, weight, and sex tend not to be
adequate predictors of EAMC occurrence.7,51,75,80
The most effective treatment for acute EAMCs is static
stretching of the affected muscle until the cramp sub-
sides.7,51,53 Stretching reduces the activity of cramping
muscles53 and may relieve cramps by increasing the
inhibition produced by the Golgi tendon organs4,76 or the
physical separation of contractile proteins (or both).53 The
effectiveness of chronic or acute static stretching as
prophylaxis against future EAMC episodes is unknown.
Those patients with EAMCs related to a whole-body
sodium deficit must be promptly treated with a high-salt
solution, either orally or intravenously. However, it is
important to note that this treatment will not result in
immediate relief of muscle cramping because of the time
necessary to properly absorb sodium.
No well-designed, controlled cohort or experimental
studies have compared the effectiveness of EAMC
prophylactics, yet some case studies suggest that fluid and
electrolyte monitoring and replacement9 or neuromuscular
reeducation49 may effectively reduce EAMC recurrence.
Hyperthermia and EHS
Signs and symptoms of hyperthermia include dizziness,
confusion, behavioral changes, coordination difficulties,
decreased cognitive function, reduced physical perfor-
mance, and collapse.15,52,69,71,72,81,82 The residual effects
of elevated core body temperature depend on the duration,
not necessarily the degree, of the hyperthermia.46,57,69,82
Moderate exercise-induced hyperthermia is normal and
even protective in that it triggers the body’s thermoregu-
latory system. However, with EHS (core body temperature
greater than 40.58C [1058F]), long-term neurologic deficits
are possible if the condition is not quickly recognized and
treated. When EHS is immediately treated via rapid whole-
body cooling and core body temperature is normalized
within 30 minutes of collapse, a 100% survival rate with
limited or no sequelae has been reported.57,69
The fastest way to decrease core body temperature is full-
body CWI in a pool or tub (with a water temperature
between 18C [358F] and 158C [(598F]).57,61,69 Timely (less
than 30 minutes from the time of collapse) CWI therapy
was associated with a 0% fatality rate in more than 2000
Table 5. Example of Wet-Bulb Globe Temperature (WBGT) Guidelinesa
WBGT Reading Activity Guidelines and Rest-Break Guidelines
Under 82.08F (27.88C) Normal activities: provide 3 separate rest breaks/h of minimum duration 3 min each during workout.
82.0–86.98F (27.88C–30.58C) Use discretion for intense or prolonged exercise. Watch at-risk players carefully. Provide 3 separate rest
breaks/h of minimum duration 4 min each.
87.08F–89.98F (30.58C–32.28C) Maximum practice time ¼ 2 h. For football: players restricted to helmet, shoulder pads, and shorts during
practice. All protective equipment must be removed for conditioning activities. For all sports: provide 4
separate rest breaks/h of minimum duration 4 min each.
90.0–92.08F (32.28C–33.38C) Maximum length of practice ¼ 1 h. No protective equipment may be worn during practice and there may be
no conditioning activities. There must be 20 min of rest breaks provided during the hour of practice.
Over 92.18F (33.48C) No outdoor workouts, cancel exercise, delay practices until a cooler WBGT reading occurs.
Guidelines for hydration and rest breaks
1. Rest time should involve both unlimited hydration intake (water or electrolyte drinks) and rest without any activity involved.
2. For football, helmets should be removed during rest time.
3. The site of the rest time should be a ‘‘cooling zone’’ and not in direct sunlight.
4. When the WBGT reading is greater than 868F (308C):
a. Ice towels and spray bottles filled with ice water should be available at the ‘‘cooling zone’’ to aid the cooling process.
b. Cold-immersion tubs must be available for practices for the benefit of any player showing early signs of heat illness.
Definitions
1. Practice: The period of time that a participant engages in a coach-supervised, school-approved sport or conditioning-related activity.
Practices are timed from the time the players report to the field until they leave the field.
2. Walk-through: This period of time shall last no more than 1 h, is not considered to be a part of the practice-time regulation, and may not
involve conditioning or weight-room activities. Players may not wear protective equipment.
a
Example originates from Georgia High School Athletics Association wet-bulb globe temperature guidelines and is only applicable to those
who practice, condition, train, or compete under similar environmental conditions. Guidelines should be region specific and based on the
following criteria: (1) environmental conditions, (2) intensity of activity, (3) heat-acclimatization status, (4) equipment and clothing, (5)
fitness of individual, and (6) age of participants.

EHS patients in athletics and military settings. Other forms
of cooling (eg, cold-water dousing with fans, ice-water
towels) may be used if CWI is not available, but these
methods decrease core body temperature at a slower rate
than does CWI.61,62,69
Environmental Risk Factors
Environmental Conditions. Hot and humid environ-
mental conditions can more readily predispose an
individual to EHS.* When the environmental temperature
is higher than the body’s skin temperature, individuals
absorb heat from the environment, and their heat loss
depends entirely on evaporation. 17,30,71,72 Yet when
humidity is also high, evaporative heat loss is severely
diminished, which can lead to a rapid rise in core body
temperature and an extreme risk for EHS (Table 5).
The environmental factors that influence the risk of heat
illness include the ambient temperature, relative humidity
(amount of water vapor in the air), air motion (wind speed),
and amount of radiant heat from the sun. The relative risk
of heat illness can be calculated using the WBGT equation:
WBGT ¼ ðwet-bulb temperature 3 0:7Þ
þ ðblack-globe temperature 3 0:2Þ
þ ðdry-bulb temperature 3 0:1Þ:
This equation is used to estimate the risk associated with
exercise based on environmental conditions and can be
useful for setting local policies regarding environmental
heat. The WBGT index has long been used in athletics and
by the US military. Using the WBGT index to modify
activity in high-risk settings has greatly diminished the
occurrence of EHS cases in US Marine Corps recruits.
However, due to geographical differences among athletic
* References 17, 22, 23, 30, 33, 71, 72, 83, 85
teams and schools across the United States, the WBGT
index may not be the most appropriate tool in determining a
universal policy for activity modifications and cancella-
tions.84 Therefore, caution is necessary when setting
protocols based solely on climate due to differences among
the various regions of the country. It should be noted that an
EHI could occur in seemingly ‘‘normal’’ environmental
conditions and, therefore, all appropriate precautions
should be taken, especially in the first week of practice
(Table 6).
Barriers to Evaporative Heat Loss. Athletic equipment
and rubber or plastic suits used for weight loss do not allow
water vapor to pass from the skin to the environment and,
as a result, inhibit evaporative, convective, and radiant heat
loss.27,42,86,87 Participants who wear equipment that does
not allow for heat dissipation are at an increased risk for
heat illness. Wearing a helmet is also a risk factor because a
significant amount of heat is dissipated through the head.
Individuals are most susceptible to EHI during the first
week of preseason practices.29,88,89 Thus, it is important to
include a phase-in of equipment as part of the heat-
acclimatization period.
Wet-Bulb Globe Temperature the Previous Day and
ð2Þ Night. When individuals compete in high WBGT
conditions, the risk of EHI increases the following day.91
This factor appears to be one of the best predictors of EHI
and should be considered when planning successive
practice sessions. Additionally, individuals who sleep in
warm or non–air-conditioned quarters are also at greater
risk due to the cumulative effects of heat exposure.
Excessive Clothing or Equipment. Excessive clothing
or equipment decreases the body’s ability to thermoregulate
and may cause greater absorption of radiant heat from the
environment.

Journal of Athletic Training 995

Table 6. Risk Factors for Exertional Heat Stroke69,90
Extrinsic Risk Factors
High ambient temperature, solar radiation, and high humidity
Athletic gear or uniforms
Peer or organizational pressure
Inappropriate work-to-rest ratios based on intensity, wet-bulb globe
temperature, clothing, equipment, fitness, and athlete’s medical
condition
Predisposing medical conditions
Lack of education and awareness of heat illnesses among coaches,
athletes, and medical staff
No emergency plan to identify and treat exertional heat illnesses
Minimal access to fluids before and during practice and rest breaks
Delay in recognition of early warning signs
Nonenvironmental Risk Factors
Heat Acclimatization. Heat acclimatization is a
physiologic response to repeated heat exposure during
exercise over the course of 10 to 14 days.24,25,92 This
response enables the body to cope more effectively with
thermal stressors and consists of increases in stroke volume
and sweat rate and decreases in heart rate, core body
temperature, skin temperature, and sweat salt losses.17,93,94
Athletes should be allowed to acclimatize to the heat
sufficiently before stressful conditions such as full
equipment, multiple practices within a day, or
performance trials are implemented.16,23,26,27,88 Individual
differences affect the onset and decay of heat
acclimatization.24,25 The rate of acclimatization is related
to aerobic conditioning and fitness; in general, a better
conditioned athlete will acclimatize to the heat more
quickly.
Exercise Intensity. The rate of metabolic heat production
is clearly a function of the intensity of physical exertion.
The relative intensity of exercise, which is based in part on
individual physical fitness, has the greatest influence on the
rate of increase in core body temperature.94 From a
physiologic standpoint, high-intensity exercise results in a
substantial amount of metabolic heat production, which then
produces a rapid rise in core body temperature.95–97 This
rapid rise in temperature often exceeds the ability of the
body to dissipate heat, ultimately overwhelming the
thermoregulatory system. From a behavioral standpoint,
individuals will often use an anticipatory defense
mechanism and behavioral modifications (eg, slowing
their pace) to protect themselves against dangerous levels
of hyperthermia.98,99 However, during competition, the will
to win or to accomplish a personal best may trump this
internal cue. In addition, external pressure from coaches or
teammates may force athletes to ignore this protective
instinct.54,88
Overzealousness. Overzealous athletes are at higher risk
for EHI because they tend to override the normal behavioral
adaptations to heat and ignore early warning signs of
EHI.42,88
Poor Physical Condition. Untrained individuals are
more susceptible to EHI than trained individuals because,
as aerobic power (V̇O2max) improves, the ability to
withstand heat stress generally also improves.42,44–46
High-intensity exercise can readily produce 1000 kcal/h
and elevate the core temperature of at-risk athletes (those
who are unfit, overweight, or unacclimatized) to a
dangerous level in less than 30 minutes.94
996 Volume 50  Number 9  September 2015
Intrinsic Risk Factors
High intensity of exercise and/or poor physical conditioning
Sleep loss
Dehydration or inadequate water intake
Use of diuretics or certain medications (ie, antihistamines, diuretics,
antihypertensives, attention-deficit hyperactive disorder drugs)
Overzealousness or reluctance to report problems, issues, or illnesses
Inadequate heat acclimatization
High muscle mass-to-body fat ratio
Presence of a fever
Skin disorder
Increased Body Mass Index. Obese people are at
increased risk for EHI because they are less efficient in
dissipating heat and produce more metabolic heat during
exercise. Conversely, those who are muscle bound produce
increased metabolic heat and have a lower ratio of surface
area to mass, contributing to a decreased ability to dissipate
heat.42,100
Dehydration. Excess sweat loss, inadequate fluid intake,
vomiting, diarrhea, certain medications, and alcohol can
lead to a measureable fluid deficit. Proper hydration can
help to reduce exercise heart rate,15,34,101–103 fatigue,12,104
and core body temperature, 105,106 while improving
performance105–107 and cognitive functioning.81,108–111
Dehydration of as little as 2% of body weight can
negatively affect performance and thermoregulation.32,34
Caution should be taken to ensure that athletes arrive at
practice euhydrated (ie, having reestablished their weight
since the last practice) and replace body water that is lost
during practice. Measuring body-weight change before,
during, and after a practice or an event and across
successive days is the preferred method for monitoring
dehydration in the field. Using a clinical refractometer is
another effective method of estimating hydration status:
specific gravity should be no more than 1.020 at the start of
the activity.16,31,32,42 Hydration status can also be identified
by monitoring the first-void morning urine color via a urine
color chart (urine color should be no more than 4).31,42
Water loss that is not sufficiently regained by the next
practice increases the risk for EHI.11,27,31,32 Cumulative
dehydration develops insidiously over several days and is
typically observed during the first few days of preseason
practices112 and in tournament competition. Cumulative
dehydration can be detected by monitoring daily preprac-
tice and postpractice body weights and morning urine color.
During intense exercise in the heat, sweat rates can be as
high as 2 L/h; if the fluid is not replaced, large deficits will
result.27 Therefore, the rehydration rate may have to be
increased during exercise periods of this nature in order to
minimize fluid deficits.
Illness. Individuals who are currently or were recently ill
may be at increased risk for EHI because of fever,
dehydration, or medications (eg, decongestants or
antidiarrheal agents).27,42
History of Exertional Heat Illness. Athletes with a
history of heat illness are often at greater risk for recurrent
heat illness during strenuous physical activity due to the
potential for widespread debilitation involving the
thermoregulatory, central nervous, cardiovascular,
musculoskeletal, renal, and hepatic systems.20,33,42,65–68
However, these long-term effects are markedly reduced if
proper treatment is initiated within 10 minutes of
collapse.57 Identifying the cause of the heat illness and
making appropriate decisions to correct the cause will
decrease the risk of subsequent heat illnesses.66 Therefore,
the clinician’s thorough understanding of the common
causes and predisposing factors of EHI is extremely
important. Addressing these common causes and
implementing proper strategies to mitigate their harmful
effects may be the most important approach in avoiding
EHIs.
Medications and Drugs. Individuals who take certain
medications or drugs, particularly those with a dehydrating
effect or those that increase metabolic rate, are at increased
risk for EHI.113–116 Medications that have been suggested to
have an adverse effect on thermoregulation include
stimulants, antihistamines, anticholinergics, and
antipsychotics.116 Approximately one-third of high school
football players reportedly used dietary supplements, most
for the purpose of increasing muscle mass.113 Although
such substances do not preclude participation, clinicians
should recognize that these athletes are at higher risk and
ensure adherence to acclimatization and hydration
strategies and observe and intervene to protect if the
athlete appears to be struggling.
Electrolyte Imbalance. Electrolyte imbalances can
occur even in trained, acclimatized individuals who
engage in regular physical activity and eat a normal diet.
Most sodium and chloride losses occur through the urine,
but people with high sweat rates (eg, .2 L/h) and sodium
concentrations and those who are not heat acclimatized can
lose significant amounts of sodium during physical activity.
It is important to emphasize that athletes’ meals should
replace electrolyte losses and thereby allow them to avoid
salt-depletion dehydration. Electrolyte imbalances also
commonly arise with the use of diuretics.117,118
Hospitalization and Recovery
After an episode of EHS, the patient may experience
impaired thermoregulation, persistent CNS dysfunction,
hepatic insufficiency, and renal insufficiency.65–67,119 For
persons with EHS and associated multisystem tissue
damage, the rate of recovery is highly individualized,
ranging up to more than 1 year.65,119–121 However, evidence
indicates that the degree of morbidity is negatively
associated with proper recognition and treatment.69 If
EHS is quickly recognized and immediately treated,
morbidity and mortality are significantly decreased.
A patient who experiences EHS may have compromised
heat tolerance and heat acclimatization even after physician
clearance. Additional heat stress may reduce the patient’s
ability to train and compete due to impaired cardiovascular
and thermoregulatory responses.65,67 After recovery from
EHS, an athlete’s physical activity should be restricted and
the gradual return to sport individualized by a physician.
The patient should be monitored daily by the clinician
during exercise. During the return to exercise, the patient
may experience some detraining and deconditioning not
directly related to the EHS. He or she should be evaluated
over time to determine if there has been complete recovery
of exercise and heat tolerance.
Certified athletic trainers and other allied health care
providers must be able to differentiate EAMCs, heat
syncope, heat exhaustion, exertional heat injury, and EHS
in order to treat these conditions appropriately in athletes.
This position statement outlines the NATA’s current
recommendations to reduce the incidence, improve the
recognition, and optimize the treatment of these heat
illnesses in athletes. Education and increased awareness
will help to reduce both the frequency and severity of heat
illnesses in athletes.
ACKNOWLEDGMENTS
We gratefully acknowledge the efforts of William M. Adams,
MS, ATC; Chad Asplund, MD, MPH; Michele Benz, MS, LAT,
ATC, CSCS; Yuri Hosokawa, MAT, ATC; Glen P. Kenny, PhD;
Brendon P. McDermott, PhD, ATC, and the Pronouncements
Committee in the review of this document.
DISCLAIMER
The NATA and NATA Foundation publish position
statements as a service to promote the awareness of certain
issues to members. The information contained in the
position statement is neither exhaustive nor exclusive to
all circumstances or individuals. Variables such as
institutional human resource guidelines, state or federal
statutes, rules, or regulations, as well as regional environ-
mental conditions, may impact the relevance and imple-
mentation of these recommendations. The NATA and
NATA Foundation advise members and others to carefully
and independently consider each of the recommendations
(including the applicability of same to any particular
circumstance or individual). The position statement should
not be relied upon as an independent basis for care but
rather as a resource available to NATA members or others.
Moreover, no opinion is expressed herein regarding the
quality of care that adheres to or differs from the NATA
and NATA Foundation position statements. The NATA and
NATA Foundation reserve the right to rescind or modify its
position statements at any time.
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Hillside Road, Box U-1110, Storrs, CT 06269-1110. Address e-mail to douglas.casa@uconn.edu.
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